Thursday, February 28, 2013

By popular request, I have now issued an audiobook version of my book Goal Play! Leadership Lessons from the Soccer Field. The book has sold thousands of copies in paperback and on Kindle, but many of you have asked for a version to which you can listen.

I hope you enjoy it. I did most of the narration myself (see above for an actual outtake!), but other people have taken on some of the roles in the book--including the foreword written by Edgar Schein--and I think you will like the production quality and sound effects. (You can listen to that section of the book here, at my other blog on Wordpress, which permits inclusion of audiofiles in blog posts.)

I had to make a choice about distribution of the audiobook. Some suggested using Audible.com, but their terms and conditions are a bit unfriendly for a self-produced audiobook. Instead, I decided to disintermediate them and use a service called PayLoadz. This is a simple front-end that connects to fulfillment through Paypal. You click on the purchase link on this home page and immediately are given a PayPal screen, where you can use your PayPal account or a credit card. Then, you are provided with a link that contains the audiobook, and you download it.

I've set it up so that the entire book is in one compressed file that you can unzip (on PCs) or unstuff (on Macs). After you download, you can save it to your hard drive or copy it to a CD or a thumb drive or whatever you like.

In coming weeks, I may also offer a CD version of the book. I have deferred this for now because it involves a different kind of fulfillment. Please let me know if that would be more helpful to you.

Wednesday, February 27, 2013

I’ve often wondered why the
psychiatric wards are the most drab and depressing parts of hospitals.
After all, you’d think that the architects and interior designers would
be instructed by the facilities administrators to brighten things up for
those patients suffering from mental illness and for the clinical staff
who take care of them. But no. You know, even from the outside of the
ward, that this is an unpleasant environment. The door to a locked
ward, with at best a small window looking in and out, is placed at the
end of a dark corridor, surrounded by a wall colored in institutional
gray or green, and often with no sign indicating what is inside. Hope
is quashed.

That despair is precisely what Teresa Pasquini, the mother of a young man
with mental disease, noticed at Contra Costa Medical Center in Martinez,
CA. She notes: “The doors of the psychiatric units were seen as the
hospital’s property and a way to control access. Visitors were also
controlled, and the mysterious world of the psychiatric units were
misunderstood and often feared. The entry into this emergency service
was bare and unwelcoming.”

But change was possible, through a broadly inclusive Lean behavioral
health rapid improvement event. She explains: “The Lean process takes
you away from the meeting room and puts you on the front line of care
observing each process. This allows you to recognize what is waste and
what has value. Lean lets you see across the silos of the system and
recognize the delays, the redundancies and harm.”

Indeed, while much of the focus of Lean is often on waste attributed
to classical manufacturing concepts like excess transport, inventory,
and waiting, those of us engaged in Lean often point out that one of the
key wastes is “the waste of human potential.” Unfortunately, if there
is ever a part of a hospital that is likely to feature the waste of
human potential--both of staff and patients--it is in the mental health
areas.

Look at this simple result. Teresa explains: “With the help of a
community partnership and three mental health consumers, who designed
and painted the entrance to the psychiatric emergency area, this door
now symbolizes the commitment to patient and family partnership and to
co-producing a more welcoming and accessible experience for all who come
here for care.”

I did a double-take after glancing at this chart posted on the wall in the obstetrics department at Contra Costa Regional Medical Center in Martinez, CA. What were those terrible peaks in the record of pre-39 week elective induced deliveries? Then I looked more closely and realized what the scale was on the vertical axis. Each of the two peaks represented only one such delivery! The rate during those two months remained below 1%. And one of the two deliveries was only one day short of 39 weeks. For the rest of the three years shown, the statistic stayed resolutely at zero.

I immediately spun around to the chief nurse on the floor, "How'd you do that?" I had in mind the experience of so many other hospitals, including those in Massachusetts, which have had much higher rates and only recently have focused attention on this issue. (The problem being that pre-39 week babies suffer distress and problems much more often than full term babies. This puts them at risk and sometimes requires visits to the intensive care unit.)

Her response was way too simple: "We collectively agreed that this was a serious issue and that we would religiously follow the criteria for early induction laid out by ACOG (the American College of Obstetricians and Gynecologists.) If a doctor shows up wanting to induce an earlier delivery, any person on the staff is empowered to question the decision. In case of conflicting opinion, we jointly discuss it."

For those who want to follow the lead of this public hospital in California, check out the ACOG Practice Bulletin, "Clinical Management Guidelines for Obstetrician-Gynecologists: Induction of Labor," Number 107, August 2009.

Oh, by the way, did you notice that I said that the chart above was on the wall for all to see? That's the kind of transparency that helps an organization hold itself accountable to the high standards it has set for itself. Notice, too, that the goal is zero, not some national benchmark. As I have said before, there is no virtue in benchmarking yourself to a substandard norm. Bravo on all fronts to CCRMC.

Tuesday, February 26, 2013

Teresa Pasquini (above, left) is a self-styled rabble rouser, "the queen of the letter writers," who used to spend hours trying to get her local hospital to do a better job caring for patients. Who better then for CEO Anna Roth (above, right) to recruit as one of the first Family Member Partners for the Contra Costa County Regional Medical Center & Health Centers.Patient-family advisory councils have been described as "the next blockbuster drug," the single most important advance in the delivery of medical care that is likely to show up in hospitals. I had the pleasure today as Teresa and Anna participated in a webinar offered by the National Association of Public Hospitals on the topic of patient an family engagement. Appropriately, most of the time in the webinar was taken by Teresa describing her motivation and involvement in the PFE process. Her first statement got my attention, and the rest of her talk kept it. Here are some excerpts:

I need to start my comments by sharing what drives my passion and commitment to this work. I am the proud mom of a 30-year-old son with schizoaffective disorder who has spent the majority of the past 14 years in psychiatric facilities behind locked doors.

Doors, hope and harm have been a running theme in our life since our son was diagnosed.

My son has been hospitalized over 30 times in several locked facilities. The past 14 years have been a blur of suicide attempts, over 40 involuntary holds, revolving hospitalizations, and a permanent conservatorship. With a diagnosis at age 16, we began to navigate a maze of services in one of the most integrated health care systems. It was a nightmare.

I was an angry mom when I was invited to my first Lean event at CCRMC.

Prior to this event, there was concern about me whispered around the tables and behind closed doors. Cautious warnings were shared about my outspoken, even radical, direct action approach. Fortunately, the Administration of CCRMC took a risk and opened their doors and minds and even encouraged me to push them forward. The first event was the beginning of a special human connection that ignited our shared vision of hope.

Our partnership started off without clear direction. There were underlying control issues. We moved cautiously building trust and respect. By staying at the table we began to overcome our fears and find our way to the "field beyond right and wrong."

We were teaching and learning together and laying down the tools that had been failing. We were challenging the system and embracing the tension that comes from change. And there was tension.

The tension was often whispered offline or subtly felt in meetings. The staff was not trained to be open with "outsiders" in the room. The patients and families were not familiar with "medicine speak." But through determination, courage, and leadership, the comfort level increased and transformation began.

Contra Costa County Health Services has shown bold courage by offering our community a trusting, authentic, shared learning experience and partnership that goes beyond the traditional advisory role. We are not token advisors but rather equal and respected partners. We have learned to speak the truth, hear the truth, and go and see the truth. With constancy of purpose and focused direct action, we are co-creating a system where the consumers, families, community organizations, clinicians and staff work in a true partnership. No politics, no discrimination, no special interest, no egos, just pure ethical health care based on the needs of the patient. I have seen it happen. It is possible.Nothing is scarier that the health system when your child is sick. Please, don't be afraid of an an angry mom or patient. Invite family members like mine to tell you our experiences and let us help you create solutions. Nobody comes to work to harm others. We are the expert system navigators and we will help you design a better system for all.

The stories have now been relegated to the back pages. “… Smoldering
batteries forced safety regulators to ground Boeing’s new 787 Dreamliner
jets.” This is a glimpse into the challenges that this aircraft and
company seem to have been besieged by. The recent grounding of the fleet
comes on the heels of other safety related incidents that while
“typical” with a new plane have caused some concern given the rapid
sequencing of events.

By the estimates made by the Institute of Medicine in early 2000,
deaths from mistakes in healthcare are associated with the equivalent of
one of these planes falling out of the sky every single day. The high
estimate was of 98,000 people a year dying as a result of preventable
harm and error.

What has been remarkable to me about the Boeing story, is not so much
the incidents, not so much that the fuel leaked, or that the cockpit
alarm went off or that it took forty minutes for a fire to be
extinguished, what’s remarkable to me is that these are the stories,
these are the headlines that we are reading and that the TV networks are
carrying.

These “incidents,” for those of us who work in healthcare, are what
we refer to as “near misses” and “good catches.” No one has died, no one
has been injured, and no one has suffered anything more I suspect than a
delay in getting to his or her destination. Oh, and some bruised pride
and quarterly earnings impact for Boeing I expect.

In our hospitals, these “incidents”, these “near misses” rarely get
reported internally; the associated press and the national evening news
certainly don’t pick them up as front page stories.

If we are obsessed with safety, like the human factors focused
airline industry, our near misses and our good catches would be enough
for us to stop the line, stand back and work to develop safer systems.

So what can leaders do?

Lead a culture where you model that it is safe to speak up and
encourage people to call out near misses, report good catches and model
the mindset and actions of being personally accountable.

Make it known that while clear roles and clarity around authority are
important, everyone is personally empowered to speak up or call an
unsafe or potentially unsafe behavior to the attention of their
colleagues.

Use all meetings, from the board to the bedside, to tell stories of
how a mistake was avoided and how, when things go wrong, you recovered.

When things do go wrong because they will, we are human beings caring
for human beings, don’t point fingers and blame people. Own the
outcome, work to learn from the failure, apologize, atone and remain
open to feedback.

Adopt some of the human error mitigation systems that the airlines
have embraced. First names only and the sterile cockpit rule require
that people only address each other by their first names in the cockpit
and that during specific times only conversations pertinent to flying
the plane are permitted. We have a choice to hold ourselves to these
relatively simple agreements in our operating rooms and exam rooms.

So yes, I wish my hospital was a Dreamliner. Because Dreamliners are
not falling out of the sky; they are being stopped, checked, called
back and inspected.

Monday, February 25, 2013

With CMS, HRSA and others investing close to $9 billion dollars annually
in graduate medical education, the day has now come for greater
accountability in graduate medical education around safety and quality.
Imagine what would happen if academic medical centers
were ”reimbursed” for their graduate medical education the same way
hospitals are now being reimbursed for patient care with penalties
for lapses in safety and quality education, similar to readmission or
infection rates. A reimbursement model based on Value-Based Education
and HCAHPS for graduate medical education…where organizations like
Consumer’s Union, Healthgrades and Leapfrog would publish
annual ”grades” for GME quality and safety programs across the
country. That would surely raise the stakes, get institutional
leadership’s attention, and change the graduate medical education
landscape. Is that type of educational “transparency” heading our way in
the not-too-distant future?

About the Presentation

The world is rife with process improvement methods designed to deal
with systemic issues facing manufacturing and services firms. Although
proven tools, such as Six Sigma, Re-engineering, and Lean, exist to
build learning organizations with enhanced efficiency and deliver higher
quality products to customers, most organizations never achieve these
goals. Why do so many work redesign efforts fail?

Paul Levy offers answers in a story-laden presentation based on his
experience in several important leadership roles. These include serving
as CEO of Beth Israel Deaconess Medical Center in Boston and executive
director of the Massachusetts Water Resources Authority. Levy's
presentation will also draw from his work in coaching girls' soccer over
two decades. His recently published book, Goal Play! Leadership
Lessons from the Soccer Field, draws on experiences gleaned from both
parts of his life. Whether you are a CEO, department head, division
manager, a professional who wants to work with others to improve the
systems in your organization, or a volunteer in your community, this
presentation offers insights to help you provide value wherever you are.

About the Speaker

Paul F. Levy served most recently as CEO of Beth Israel Deaconess
Medical Center in Boston, where he saved this Harvard-affiliated
academic medical center from financial turmoil that was leading to
bankruptcy. Later, he introduced unprecedented levels of transparency
into the health care field, resulting in substantial improvements in
patient quality and safety, while enhancing financial results and market
share. Previously, as executive director of the Massachusetts Water
Resources Authority, he led the program to clean up Boston Harbor,
executing a massive environmental remediation project ahead of schedule
and under budget. He is the author of the recently published book, Goal
Play! Leadership Lessons from the Soccer Field.

About the Series

The MIT System Design and Management Program Systems Thinking
Webinar Series features research conducted by SDM faculty, alumni,
students, and industry partners. The series is designed to disseminate
information on how to employ systems thinking to address engineering,
management, and socio-political components of complex challenges.

Wednesday, February 20, 2013

It was a pleasure to join MIT Professor Ernst Berndt for his class "Economics of the Health Care Industries" at the Sloan School of Management. Tonight's topic was "Managing Health Care Costs and Quality." This class has an unusually diverse group of students--undergraduates from MIT, Wellesley, and Tufts; MBA students; executive MBA students; and several people with MD and Ph.D. degrees. Students who offered particularly thoughtful comments are pictured here. Please hire them. (The fellow in the bottom picture wanted to make it clear how to find him!)

Ernie started off with a marvelous exposition of many factors relating to health care costs. This chart above on the concentration of health care expenses in the US was striking, showing that 5% of the population accounts for about 48% of the nation's costs.

My job was to provoke a bit of discomfort and debate, and I explored several topics with the students. I started with the question of whether the fact that health care accounts for 17.9% of GDP was a problem. If so, why? Was it too high or too low? If one looks at some of the OECD countries with lower percentages, is it
an indication that they are more efficient or that they are spending
too little? If the US number was too high, which participants in the health care system should receive less? How much less?

We then entered discussions about using payment rates as incentives for efficiency improvements. Is the failure of many pay-for-performance programs to produce meaningful results a function of poor design or a disconnect with what motivates doctors and nurses and how they make decisions?

We discussed further whether accountable care organizations would be likely to succeed, a variant on Elliot Fisher's joking comment of whether they would be accountable, caring, and organized.

I left the group with descriptions of two approaches that have been demonstrated to be successful in offering higher quality, lower cost care: Managed care programs for dual-eligible (Medicare and Medicaid) patients; and front-line driven process improvement in hospitals.

Here’s the rub about reducing health care costs to improve
your hospital’s bottom line: The “old”
solutions of cutting back on staff and services are shortsighted at
best. The best solutions require delivering better care and getting rid
of wasteful practices. Even getting bigger to achieve efficiencies and
economies of scale won’t help in the long run; the new world
pays for value over volume.
And value involves care coordination that
follows patients wherever they go, including after they leave your
hospital.

How to survive, and thrive, in this brave new world? Tune into WIHI on
February 21, 2013, for Clinicians
and Financial Staff Can Improve Quality and Lower Costs –
Stories from the Frontlines, Part Two.
This is the second installment of a focus this month on cost reduction
strategies that marry the best ideas from quality improvement with
sharpened-pencil, financial and business acumen. We’ll focus
on the work of two organizations — Northeast Health and
Hackensack University Medical Center — and we’ll
unpack how they, and some 58 other
organizations that were part of IHI’s Impacting Cost +
Quality initiative, are on track to save $43 million.

Can your hospital leadership commit to reducing costs at least two
percent over the next five years, while maintaining or improving
quality? If you can’t make that commitment today, what would
get you on the path to making it? WIHI host Madge Kaplan, with the help
of IHI’s Kathy Luther and three
dynamic hospital leaders and experts — Norm Dascher, Lucy
Savitz, and
Cathy Abbott — promise you a bold and bottom-line discussion
on the February 21 WIHI. Please join us! Sign up here.

Available evidence suggests there is significant room to improve and standardize the care that is provided to patients during in-flight medical emergencies. Even though emergency medical kits are mandated to contain certain medications and equipment, the actual kits vary from airline to airline. The US Federal Aviation Administration (FAA) mandates that flight attendants receive training “to include performance drills, in the proper use of AEDs [automated external defibrillators] and in CPR [cardiopulmonary resuscitation] at least once every 24 months.” However, the FAA “does not require a standard curriculum or standard testing.” To improve the chances that passengers who become ill during air travel will do well, airlines and their regulators could take steps similar to what they have done to ensure flight safety for all flights under FAA jurisdiction including the following.First, a standardized recording system for all in-flight medical emergencies should be adopted, with mandatory reporting of each incident to the National Transportation Safety Board, the organization responsible for reviewing safety events and recommending changes to practice. This approach should include a systematic debriefing of anyone directly involved with the in-flight medical emergency. Wherever possible, this debriefing should happen immediately; otherwise, follow-up telephone interviews should be conducted.Second, based initially on expert recommendations and later on the results of reporting, the optimal content of the first aid kits on airplanes should be determined, with a man-date that a standard kit, with identical elements, in identical locations, be on every flight.Third, the training of flight attendants in how to deal with medical emergencies should be enhanced and standardized.Fourth, access of flight crews to ground-to-air medical support should be standardized. If this form of support is deemed to be effective, then it should be available to all passengers, on all flights when on-plane health care professionals are not available.With standard emergency medical kits and standardized training of flight personnel, it will become possible to provide to physicians and nurses some rudimentary training in in-flight medical emergencies.Because the airline industry has already developed standardized reporting and responses to many forms of in-flight emergencies, the adoption of these measures by airlines and their regulators should not add a great deal of expense, but such sensible measures have the potential to improve outcomes for airline passengers who become ill.

Airline safety has been improving in North America, Europe, and Asia as a result of a number of coordinated efforts on the part of
international organizations and national regulatory authorities, as well
as voluntary safety programs adopted by air carriers and repair
stations. The emphasis in safety improvements has shifted from technical
improvements to systemic improvements in organizational safety
culture.

But Sully reminds us:

“It’s important not to define safety as the absence of accidents,” said Chesley B. Sullenberger III, the US Airways pilot who became a hero
when he landed an Airbus A320 in the Hudson River in January 2009 after
both engines lost power. All 155 aboard escaped.

“When we’ve been through a very safe period, it is easy to think it’s
because we are doing everything right,” he said. “But it may be that we
are doing some things right, but not everything. We can’t relax.”

Many doctors and hospital administrators disagree when suggestions are made that there can be parallels between health care and air transport, or between health care and manufacturing, or between health care and virtually any other field of endeavor. They are wrong. Those of us who have been involved in quality and safety improvement know that there is much to be learned from other fields.

The big difference to date between health care and other fields is the lack of acceptance by the medical community of Sully's last point: "We can't relax." We are too quick to claim victory, or even progress, in the reduction of patient harm. I made this point last week in my post about central line infections. With the national and state focus on cost reduction, we are in danger of having a skewed perspective about what matters.

What matters is redesigning the work in hospitals to help avoid the systemic problems that cause harm to patients. On this front, we are deficient. The hospitals that have done the best in this area are usually the most modest about their progress. They are the first to admit that so much more needs to be done even in their own facilities. The hospitals that have not yet addressed the issue are suffering from a dramatic failure of leadership--from their boards, their administrators, and their clinicians. If the airlines killed as many people in their care, they would be shut down within days.

Sunday, February 17, 2013

@dallasnews The Dallas Morning News has been deeply involved in following the many troubles of Parkland Memorial Hospital, and recently offered a story of deep divisions between the hospital and its affiliated medical school, University of Texas Southwestern Medical Center. The picture given of this relationship provides an extreme example of dysfunctionality, but the underlying pressures that exist to create that strife exist to a greater or lesser degree in many cities in the US.

Academic medical centers are the crown jewels of American medicine, where extremely well intentioned people provide innovation in patient care, research, and education. But they can also be the intersections of the worst characteristics of two sectors--medicine and academia--with people of great intelligence, big egos, and poor interpersonal skills. If issues of governance and priorities are not addressed explicitly and with good will, there can be dangerous results for patients and unpleasant working conditions for all.

An excerpt:

Publicly, Parkland Memorial Hospital and its affiliated medical
school, UT Southwestern Medical Center, present a united front. Behind the scenes, however, the reality has been far different

The tension between the two institutions reflects their tangled
relationship. Parkland actually has little control over the doctors
working under its own roof. Most are employed by, or answer to, UTSW.
Parkland’s priority is supposed to be patient care. Yet UTSW lists its
missions as medical education, research and patient care — in that
order.

The organizations’ divergent missions, business interests and turf
battles contributed to a dysfunctional culture at Parkland over the last
decade, jeopardizing patient care. Federal safety monitors have flagged the culture as a major factor in
plunging Dallas County’s hospital for the poor and uninsured into its
safety crisis.

Many times over the last decade, UTSW faculty physicians have failed
to show up to care for Parkland’s patients. Instead, they see privately
insured patients at the medical school’s separate system of hospitals,
or focus on research. Resident doctors-in-training at Parkland often
have been left with little or no faculty supervision. And front-line
caregivers who report to the doctors, especially nurses, have felt
powerless to resolve patient-care breakdowns.

Trust and transparency issues abound.

And further into the story, we get some details:

In reality, there are two separate chains of command inside Parkland.

Parkland’s chief medical officer, for example, is supposed to provide
leadership over clinical affairs and quality of care at the hospital.
Yet the UTSW president “is actively involved in the selection, regular
evaluation and decision to continue or terminate the employment of the
CMO,” according to the affiliation pact. The current interim chief
medical officer is a UTSW faculty member paid by the university, not
Parkland.

Employees say the system — what some call the “two-headed beast” — fosters confusion and chaos. UTSW medical directors, for example, are expected to collaborate with
Parkland department directors on decisions. But the structure stymies
cooperation.“Ideally, they’re supposed to meet and discuss the best approach to
provide the best of care for patients,” said a former Parkland nurse who
has filed a legal claim against the hospital and requested anonymity
for fear of retaliation. “What occurs is: they collide. Both have power
and both want control.”

Thursday, February 14, 2013

This question from a nurse patient safety specialist in the Midwest US showed up on a patient safety list-serve run by the National Patient Safety Foundation:

We
do not currently have any solidly trained human factors engineering
employees in our team. I have enough knowledge of human factors (and enough clinical
experience) to recognize how easy it is to make a bad decision. How
did you get your training in human factors? I do have some training,
but would not consider myself an expert by any means. I know enough to
be concerned that I know so little!

Eric Streicher at MedStar, which has a strong program in this area through its affiliated National Center for Human Factors in Healthcare, graciously answered: "See the University of Wisconsin Center for Quality and Productivity Improvement course on human factors and patient safety." This made me curious, and I found an excellent short course described:Today, CQPI’s Systems Engineering Initiative for Patient Safety
(SEIPS) is the foremost leader in applying Human Factors and Systems
Engineering to the patient safety challenge.

The SEIPS Human Factors and Patient Safety short course is designed
to provide an understanding of human factors and systems engineering and
how these patient safety approaches can improve performance, prevent
harm when error does occur, help systems recover from error, and
mitigate further harm.

This course is designed for all physicians, nurses, physician
assistants, pharmacists, engineers, patient safety officers, chief
information officers, and other professionals interested in human
factors engineering and patient safety.

This is an area that deserves greater attention. As the folks at MedStar note:

Human Factors is applied to healthcare to
design processes, devices, and systems that support the work of care
givers in medicine. Specific benefits of Human Factors and System
Safety Engineering applied to healthcare include:

Efficient care processes in medical care

Effective communication between medical care providers

Better understanding of a patient’s current medical condition

Implementation of effective and sustainable RCA solutions

Reduced risk of medical device use error

Easier to use (or more intuitive) devices

Reduced risk of health IT-related Use error

Easier to use (or more intuitive) health IT

Reduced need for training

Easier repair and maintenance

Cost savings through prevention and mitigation of adverse events

Safer working conditions in medicine

Improved patient outcomes

Human Factors evaluations and interventions should take place early
in the design and system development process. It should include tools
such as work domain analysis, function allocation, probabilistic risk
assessment, usability testing, among others.

Wednesday, February 13, 2013

I have been flooded with emails from people sending me the link to the newest report from the Centers for Disease Control about the "dramatic" reductions in CLABSIs: "A 41 percent reduction in central line-associated bloodstream infections since 2008, up from the 32 percent reduction reported in 2010."

The CDC reminds us:

A central line is a tube that is placed in a large vein of a patient's
neck or chest to give important medical treatment. When not put in
correctly or kept clean, central lines can become a freeway for germs to
enter the body and cause serious bloodstream infections. CDC estimates
that 12,400 central line-associated bloodstream infections occurred in
2011, costing one payer, the Centers for Medicare & Medicaid
Services (CMS), approximately $26,000 per infection.

Not to mention killing people unnecessarily.

I say without hesitation that this is not good enough. First, the CDC insists on using flawed standardized infection ratios. Per the CDC, "the SIR is a summary measure used to track healthcare-associated
infections over time. It adjusts for the fact that each healthcare
facility treats different types of patients. The SIR compares the number
of infections reported to NHSN in 2011 to the number of infections that
would be predicted based on national, historical baseline data."

"The predicted number is an estimated number of HAIs based on infections reported to NHSN during January 2006–December 2008."

In other words, a period of time during which most hospitals were doing very, very little to prevent infections.

There is no virtue in benchmarking yourself to a substandard norm. As noted by Catherine
Carson, Director, Quality & Patient Safety at Daughters of Charity
Health System:

When the goal is zero – as in zero
hospital-acquired infections, or falls – why seek a benchmark? A
benchmark would then send the message - that in comparison to X, our
current performance level is okay, which is a false message when the
goal of harm is zero.

Second, whatever metric you choose, the overall progress is just too slow. In terms of protocols and training and auditing, we know what it takes to avoid CLABSIs. For details, call Peter Pronovost. This is not a technical problem: It is a problem of leadership. It takes clinical leadership, administrative leadership, and supportive
governance to make it happen. At least one of these ingredients is
missing in too many hospitals.

It is really satisfying when I see US college students engaged in world health issues. They bring a wonderful level of idealism and enthusiasm, plus new ideas. Of course, too, they get to meet and work with people from different cultures and economic situations, something important to their own development as world citizens.

How much more so when their activities follow in the footsteps of parents who have likewise made contributions to the world. So, I was really pleased to see this story from Notre Dame University in which Katherine Spencer is quoted as explaining the purpose and goals of a program called GlobeMed. Kate is the daughter of the late Monique Doyle Spencer, who is well known to my regular readers.Kate carries her own well in this story, and her mother would have been proud. Excerpts:

The new chapter became part of a student-run non-profit organization
with 50 chapters at universities across the United States, according to
junior Kate Spencer, a campaign coordinator with GlobeMed. As part of the organization, each chapter partners with a
community-based grassroots organization facing health disparities in
Africa, Asia, North America, and South America, Spencer said.

“[Our] chapters build these partnerships through frequent communication
and innovative fundraising initiatives for collaborative health
projects that help our partner organizations achieve their missions,”
she said. Discussions on global health issues prevail in the classroom while
internships are also arranged with partner organizations overseas.

Spencer said the GlobeMed organization paired the Notre Dame chapter with the Laos network and students were thrilled to be working with them. PEDA is a non-profit organization based in Vientiane, Laos.

“Working with PEDA would give [GlobeMed
members] the opportunity to make a tangible difference in Laos, but
also educate students at Notre Dame about a country halfway around the
world with a rich culture and history,” she said.

Spencer noted that the excitement to participate in GlobeMed was mutual.

“This is an opportunity for us to collaborate with GlobeMed
and its students to improve the health of the communities, to exchange
experiences about our works, open our ear to listen to new ideas from
young generation...” chairman assistant and project coordinator at PEDAThipphavanhThammachith said through GlobeMed’s
Notre Dame chapter. “That we may apply new ideas to our work and on the
community projects, as our work is to provide technical information and
education to support the community potential in solving socio-economic,
health issues and so forth.

Offering a unique and opening environment, GlobeMed
provides many windows for involvement for all majors and those
interested in global health. Spencer said the chapter is always looking
for more members.

“We truly believe that health is a human right, and that we, as students, can be powerful agents of change,” Spencer said.

Tuesday, February 12, 2013

It has been two years since I left my job as CEO of a
hospital, and I have had many opportunities to reflect upon what I learned
during my nine-year tenure there as well as during this period afterward.It was a privilege to serve in that role,
working with so many well-intentioned people, both on the staff and among the
governing bodies and the hospital’s supporters in the community.As someone who had had no exposure to the
health care world, it was also a revelation to me to see how difficult it was
to consistently offer high-quality, patient-centered care.I learned, too, how much harm is
inadvertently caused by the way work is organized in hospitals and how
ill-suited professional training programs are in enabling clinicians to engage
in process improvement.I also made my share of mistakes, one of which in particular received a
great deal of public attention, punishment from my Board of Directors, and
apologies from me to them, the hospital staff, and even to you, my loyal readers.

Upon leaving BIDMC, I decided I would devote this next period of
my life to reflecting on what I had learned, trying to consolidate the lessons,
and then offering myself to other hospitals and communities to pass along things
that might be helpful to them.Almost
immediately, I was challenged by some people with doubts.Shortly after publishing my book Goal
Play!, one reporter asked:

I’m sure you know, there are some people out there who feel like you lost the
ability to write a book about leadership and management because of this failure
in leadership in this incident when you were at Beth Israel. How much
credibility do you think you still have as someone who can talk about
leadership and management?

I responded by saying:

Well, if you lose the
ability to talk about leadership because you make a mistake, even a big
mistake, then there aren’t going to be many people who can talk about
leadership. I think the sign of any good leader — or, for that matter, any
person — who wants to improve is [that] you acknowledge your mistakes and you see if
there are lessons to be drawn from them and, in the case of this book, perhaps
teach other people from that experience and go on.

That was easy enough to say, but the proof of the pudding
would be how I was actually received as I wrote the book and this blog and traveled the globe telling stories and offering
advice. On that front, so far so good, and I am grateful to my readers here, to those who have sent me kind notes about the book, and to other folks for their respectful attention, engagement, and encouragement.

Nonetheless, I make no claims to bringing the level of eloquence and persuasion that might be possible. I am inspired, though, bythese remarks made by E. B. White (in absentia) upon receiving the
National Medal for Literature in December 1971. If I ever become as good a
writer and presenter as he, I shall die happy. Meanwhile, I keep at it, trying not
to be discouraged at the degree of harm caused by well intentioned
people in the health care field and my inability to motivate, teach, and help as much as I would like.

The Egg Is All Ten years ago they pulled the railroad out from under me, and this almost severed my connection
with New York. Then sixteen months ago, I met with a motor accident, and this made the highway
a problem for me. As for the skies, I quit using the flying machines in 1929 after the pilot of one of
them, blinded by snow, handed the chart to me and asked me to find the Cleveland airport.The world of letters sometimes seems as remote or inaccessible to me these days as the City of
New York, and it would be foolhardy of me to comment at length on that wonderful, untidy and
seductive world. I drifted into it a long time ago with no preparation other than an abiding itch. I
fell in love with the sound of an early typewriter and have been stuck with it ever since. I believed
then, as I do now, in the goodness of the published word: it seemed to contain an essential
goodness, like the smell of leaf mold. Being a medalist at last, I can now speak of the "corpus" of
my work--the word has a splendid sound. But glancing at the skimpy accomplishments of recent
years, I find the "cadaver of my work" a more fitting phrase.I have always felt that the first duty of a writer was to ascend--to make flights, carrying others along
if he could manage it. To do this takes courage, even a certain conceit. My favorite aeronaut was
not a writer at all, he was Dr. Piccard, the balloonist, who once, in an experimental moment, made
an ascension borne aloft by two thousand small balloons, hoping that the Law of Probability would
serve him well and that when he reached the rarefied air of the stratosphere some (but not all) of the
balloons would burst and thus lower him gently to earth. But when the doctor reached the heights
to which he had aspired, he whipped out a pistol and killed about a dozen of the balloons. He
descended in flames, and the papers reported that when he jumped from the basket he was choked
with laughter. Flights of this sort are the dream of every good writer: the ascent, the surrender to
Probability, finally the flaming denouement, wracked with laughter--or with tears.Today, with so much of earth damaged and endangered, with so much of life dispiriting or joyless,
a writer's courage can easily fail him. I feel this daily. In the face of so much bad news, how does
one sustain one's belief? Jacques Cousteau tells us that the sea is dying; he has been down there
and seen its agony. If the sea dies, so will Man die. Many tell us that the cities are dying; and if the
cities die, it will be the same as Man's own death. Seemingly, the ultimate triumph of our
chemistry is to produce a bird's egg with a shell so thin it collapses under the weight of incubation,
and there is no hatch, no young birds to carry on the tradition of flight and song. "Egg is all," quote
Dr. Alexis Romanoff, the embryologist, who spent his life examining the egg. Can this truly be the
triumph of our chemistry--to destroy all by destroying the egg?But despair is no good--for the writer, for anyone. Only hope can carry us aloft, can keep us afloat.
Only hope, and a certain faith that the incredible structure that has been fashioned by this most
strange and ingenious of all the mammals cannot end in ruin and disaster. This faith is a writer's
faith, for writing itself is an act of faith, nothing else. And it must be the writer, above all others,
who keeps it alive--choked with laughter, or with pain.

Monday, February 11, 2013

My daughter (right, above, with her sister) turns 30 this week, and I decided to send her copies of books by or about people that I have admired. I wanted her to have real books, not virtual books, because they sit there on your shelf as a reminder that you haven't read them, and eventually you do. Then, the smell of them cements the memory of their contents: Smell and memory are closely linked because the olfactory bulb is part of the brain's limbic system They will start arriving at her house today or tomorrow, in time for her Valentine's Day celebration.

As I assembled my list, it occurred to me that I do not have an understanding of who serves as heroes for this generation. When I was growing up, we had John and Robert Kennedy to motivate us, and Martin Luther King, Jr. In life and death, they set standards and told us it was all right to dream. Even people who had terrible flaws--like Lyndon Johnson and Robert Moses--were larger than life, changing the course of American society in a way that suggested that one person with energy and intent could make a difference. Authors like E. B. White taught us lessons about friendship in Charlotte's Web, but then also made us laugh while learning proper grammar. It is not an accident that many of the students who were in Mr.
Morton Harrison's fifth and sixth grade class on Long Island ended up devoting
our lives to public service or education or environmental protection.
He was a great teacher who inspired and demanded rigor. Did my daughters receive this gift from any of their teachers?

My musings led to Dag Hammarskjöld. He was the second Secretary General of the United Nations, at a time when we believed the UN represented the best of world diplomacy and the best chance for sustained peace during a time characterized by the Cold War. You may recall that he died in an
air crash in 1961 while flying to Northern Rhodesia to negotiate a
cease-fire between UN and Katanga forces. His book Markings has
some remarkable entries. I don't know if it has had any influence in your
life, but I have always found it a touchstone. Here's an excerpt about negotiation. It is as valid about interpersonal relationships in an academic medical center or community hospital--where egos reign but underlying intentions are generally noble--as it is in a diplomat's resolution of a war.

"Concerning men and their way to peace and concord--?"The truth
is so simple that it is considered a pretentious banality. Yet it is
continually being denied by our behavior. Every day furnishes new
examples.
It is more important to be aware of the grounds for your own behavior than to understand the motives of another.The other's "face" is more important than your own.If, while pleading another's cause, you are at the same time seeking something for yourself, you cannot hope to succeed.
You can only hope to find a lasting solution to a conflict if you have
learned to see the other objectively, but, at the same time, to
experience his difficulties subjectively.The man who "likes people" disposes once and for all of the man who despises them.
All first-hand experience is valuable, and he who has given up looking
for it will one day find--that he lacks what he needs: a closed mind is a
weakness, and he who approaches persons or painting or poetry without
the youthful ambition to learn a new language and so gain access to
someone else's perspective on life, let him beware.
A successful lie is doubly a lie, an error which has to be corrected is a
heavier burden than truth: only an uncompromising "honesty" can reach
the bedrock of decency which you should always expect to find, even
under deep layers of evil.
Diplomatic "finesse" must never be another word for fear of being
unpopular: that is to seek the appearance of influence at the cost of
its reality.

But then note, too, this call to action:

Never, "for the sake of peace and quiet," deny your own experience or convictions.

Sunday, February 10, 2013

Kevlar vests must have been invented for people like Al Lewis. He fearlessly goes where few dare to tread, attacking the fads and shibboleths that are propounded as truth in health care policy debates. A sign of his success is that people try not to debate him. They know they can't win, so they hope that ignoring him will allow the myths on which they are operating to persist.His latest column on the The Health Care Blog is illustrative. Here are some excerpts:

It’s not quite time to publish the obituary for by far the most
extensive patient-centered medical home (PCMH) network in the country, Community Care of North Carolina (CCNC) but it’s certainly time to spellcheck it.

This wasn’t just any old medical home – it was the “poster child” for the PCMH movement, even making it onto NPR.

Meanwhile, the overall North Carolina Medicaid budgets were frequently exceeded, by considerable margins – $1.4-billion in the last three years alone.
But few people made the connection between that unanticipated extra
spending and CCNC, because CCNC hired gold-plated consultants — first Mercer and later Milliman – to demonstrate dramatic savings from the PCMH itself.

Fortunately for Mercer, Milliman is bearing most of the scrutiny now,
being the more recent of the two studies. Their results were also
obviously impossible, showing up to $250,000,000 in annual admissions
savings despite the state spending only $114,000,000 in the year prior
to the study and despite the fact that there was no decline in
admissions.

The subsequent CCNC and Milliman defense strategy, invented by the
tobacco industry and perfected by the fossil fuel interests, has been to
“sow doubt” and emphasize tangents so that journalists need to write “he said-she said” stories and follow up on irrelevancies.

Meanwhile, CCNC and Milliman haven’t actually answered the questions that get to the heart of whether they misled people for so long on purpose or simply out of ignorance.

This is not just about North Carolina. As noted above, PCMH adherents
embraced CCNC on its way up to the point where PCMH and CCNC are joined
at the hip. So what does the PCMH movement do about these folks on the
way down? In Medicaid – the category where improved access should make
the greatest difference — adoption has slowed to a crawl even with the
9-to-1 [federal] match. Further, one of the pillars of the PCMH is prevention,
which may not save money.
At the very least, PCMH adherents, to quote the immortal words of the
great philosopher Ricky Ricardo, will have a lot of ‘splaining to do.

How can we manage the financial crisis? How do civil unrest,
religion, and rumors spread, and how is that related to epidemics and
earthquakes? Can human behavior and societal systems be studied in the
same way as biological systems and complex man-made systems?

In
this webinar, Dr. Dan Braha will demonstrate how the field of complexity
research provides clues to these intriguing questions. He will focus on
why and how complex socio-economic systems evolve and why these large
scale engineering systems fail and offer guidelines that can be applied
across industries and organizations around the world.

Thursday, February 07, 2013

My UK colleagues have had two reactions to the horrors revealed in the recent report about Staffordshire Hospital. Some have said that, while terrible, it was an isolated and unusual set of circumstances. Others have said, that while less extreme, the conditions underlying the degradations of clinical services at Staffordshire exist throughout the country. From here in the US, it is hard to judge, but I'm guessing that both views are correct. The degree of harm to patients at Staffordshire was, indeed, appalling. The level of more subtle, but real, harm at other hospitals remains. Let's look at two quotes:

The report into what has been called the biggest scandal in the modern
history of the health service found that many of the problems were due
to the efforts of the hospital to meet health-service targets, like
providing care within four hours to patients arriving at the emergency
room. It also said that in its efforts to balance its books and save $16
million in 2006 and 2007 in order to achieve so-called foundation-trust
status, which made it semi-independent of control by the central
government, the hospital laid off too many people and focused
relentlessly on external objectives rather than patient care.

Robert Francis QC, who led the public inquiry into Mid Staffordshire
NHS Foundation Trust, uncovered failings at every level of the NHS and
said the culture among healthcare staff must change. His comments come as it emerged there were 3,000 more deaths than
expected at another five NHS trusts between 2010 and last year.Mr Francis, speaking ahead of a public meeting with the
families of former patients at Stafford Hospital, said: "What we need to
avoid is yet another wholesale reorganisation of abolishing
organisations and creating new ones. This is about how people behave when they go to work and their
ability to raise concerns and be honest about what's going on in their
hospitals."

He said the change would only happen when NHS managers, clinicians
and staff started to address the failings "rather than waiting to be
told what to do from Whitehall, or by the top of the NHS".

I can almost hear many of my US colleagues say, with self-satisfaction, "This kind of thing could never happen here." But I can hear my more thoughtful colleagues saying, "It is happening here."

In the US, we start with a baseline of about 100,000 people being unnecessarily killed each year in hospitals, and many more suffering from unnecessary complications, infections, and other morbidities. In the US, we have introduced a set of metrics about clinical care, generated by bureaucratic forces, that are often arbitrary and have the potential for unintended consequences. Our accreditation process encourages "teaching to the test" as opposed to evaluating systemic issues within institutions. Likewise, our review process for graduate medical education programs fails to enforce standards of competency that ostensibly are required for residents.

In the US, we have engaged in a restructuring of the industry that shifts financial risk to doctors and hospitals and that encourages consolidation and reduces competition. Repeating our failures in investment markets, we fail to regulate providers to see if they are financially capable of absorbing risk. We celebrate the expanded role of private equity firms in owning and operating hospitals, with an ostrich-like approach to understanding how such firms create profit. The potential for short cuts and under-treatment and degradation of clinical equipment and hospital infrastructure arises in these circumstances. Meanwhile, we fail to provide the kind of real-time transparency of clinical outcomes, pricing, and financial results that would help hold institutions accountable to themselves and to the broader community.

All in all, it sounds like a setup for the kind of problems experienced by our friends across the Pond. So, let's not be so self-satisfied. There is at least one Staffordshire in our midst, and there are hundreds of other hospitals that do not make the grade for the kind of quality, safety, and transparency that you would want for members of your own family.

Scott Adams, best known for Dilbert, offers a view of how robots will reduce health care costs. Does he mean it to be humorous or real or both?

Here are some excerpts:

One of the many future benefits of robots will be a dramatic reduction
in healthcare costs. In the near term, medical robots will be little
more than search engines with excellent eyesight. They will look at your
wounds, ask questions about how you feel and then use the Internet to
determine a diagnosis and treatment strategy, just as a human doctor
does.

Now imagine a future in which household robots are the norm. Your
personal robot has far better eyesight than you, incredible pattern
recognition for diagnosing problems, and potentially more manual
dexterity than you. Your robot might have a keen sense of smell, and it
might hear so well that it can detect your pulse. I can imagine all
household robots coming equipped with medical sensors as standard
equipment, including everything from blood oxygen sensors to shock
paddles. Someday the household robot might be capable of handling 95% of
all medical problems.

The first surgical robots might cost tens-of-millions. But if a robot
can work 24-hours per day without breaks, and robot prices drop with
volume, robot surgeons will quickly become competitive with human
surgeons who earn big paychecks while working only a third of the day.
The biggest savings from robots might be an end to human errors and the
resulting reduction in medical insurance premiums, assuming robots make
fewer bad decisions.

Robots are the budget wildcard for the next generation. There's a good
chance it won't matter how much national debt we pile up today so long
as robot technology keeps improving. At some point the real cost of
healthcare, energy, construction, transportation, farming, and just
about every other basic expense will fall by 90% as robots get involved.

So don't worry about medical costs in thirty years. By then the phrase
"going to the doctor" will sound like a quaint phrase from the past,
like churning butter.

In the early days of what would prove to be, in hamster years, a long illness, Jumpy just didn’t look right: his ears were swollen and he scratched incessantly. Diagnosing either a parasitic infection or an allergic reaction, our vet treated Jumpy with the full arsenal of veterinary weapons: an antiparasite medication, along with antibiotics and painkillers.For two weeks, twice a day, one of us held the hamster while the other administered minuscule doses of what we hoped would relieve and cure him . . . but Jumpy did not improve. His ears swelled, his belly was distended and he spent most of the day huddled in his hamster castle. His treadmill never moved.I took him back to the vet, who explained our options. We could continue to treat Jumpy, every other week for the rest of his life, to the tune of some $200 per visit. Or we could end treatments—and Jumpy—with an overdose of some drug. It was left to me to decide.The irony of my situation was not lost on me. I have spent years writing about how families contend with decisions just like this: Insert a feeding tube or not, try a ventilator or let nature take its course. In the hypothetical world of writing, the answers always seemed plausible and I seemed confident.

In the real-world situation in which I found myself—with a sobbing 9-year-old boy and a quaking hamster of indeterminate age—it was less straightforward. Eventually, we agreed that it was time to end Jumpy’s suffering, that he would be cremated and that we would acknowledge and celebrate the happiness he had brought to my son....I would like to write a thank-you letter to the vet, acknowledging him for the compassion and human touch he showed to my little boy, who had just confronted the first of what is ultimately a lifetime of loss.

US employers have had a lot to say about health care costs the past
several years. Large and small companies alike have openly complained
about the apparently inexorable rise in health care spending,
skyrocketing insurance rates, and the degree to which both trends have
threatened bottom lines, restrained wages, and eroded benefits for
employees.

WIHI
Host Madge Kaplan hopes you’ll tune into the February 7 WIHI,
Employers
and Employees Can Improve Quality and Lower Costs – Stories
from the Frontlines, Part One,for
a discussion of what promises to be the next wave of employer
engagement in improving health and controlling health care costs in the
US.
As we've seen, some of the most vocal businesses have been determined
to remedy the situation by exercising their purchasing clout to get
better deals from insurers and by shifting more costs and co-pays onto
the workforce. The most enlightened have also ramped up their wellness
programs. But these “solutions” are short-term at
best, and efforts to encourage employees to get to the gym and adopt
healthier lifestyles are proving insufficient. So, what to do instead?

We'll take a deeper dive into the underlying, often chronic health
conditions affecting today’s employees. And, in a growing
number of cases, partnering and learning from health care delivery
organizations working on the very same issues — heavy health
care utilization and high costs —
with their own staff.

IHI’s Trissa Torres and Lindsay Martin have the big picture
of these exciting new developments. The February 7 WIHI will also
feature leaders from Bellin Health Care Systems and Catholic Health
Initiatives who are at advanced (Bellin) and early stages (CHI) of
“walking the talk” with their own employees. Among
other things, these providers are committed to redesigning systems to
deliver better care and better value to the community and all those
paying the bills: employers, public and private insurers, and patients
themselves.

Tuesday, February 05, 2013

A couple of weeks ago, Michael Spencer and I offered readers of this blog free copies of The Courage Muscle, A Chicken's Guide to Living with Breast Cancer, by his late wife Monique Doyle Spencer (seen above with friends). Among those requesting a copy was a gentlemen who works with a group of women who call themselves "The Sunshine Girls." I told him I would send along enough copies for all of the women. This lovely email arrived today--Monique's birthday!--from Cheryl.

I just want
to thank you for sending Richard Buchanan the books "The Courage Muscle"
- He came to a meeting/dinner with our group of ladies - "Sunshine
Girls" in our small rural Georgia town to deliver
these to us.....How special we felt! Now that it has been
delivered............and I must say read without putting it down before
it was finished..........laughing (sometimes out loud) all the
way............enjoying every minute of it..............she actually
knew how to put the words in there that we can all understand and
relate.

I wish more could see this
wonderful message she gave. For us who are survivors it was awe
inspiring - you think you are all alone with some of the experiences you
go through but then realize she has been there too.
Makes one feel better just knowing she knew it as well.

Thanks again for your generosity in sending the books. We are truly blessed by it!

No charges had been filed or citations issued Monday against the driver
of the bus, Samuel J. Jackson, as State Police continued their
investigation. They are scrutinizing witness statements and physical
evidence, examining the bus driver’s route just before the crash as well
as posted road signs along the route and preliminary results of a
collision reconstruction. Final results could take two to six weeks.

If charges are filed, I'd sure like to be Mr. Jackson's lawyer. First, bring in Bill Geary as a witness and have him explain what he did to make the roads safer in the late 1980s:

“What just occurred this weekend was something I lived in fear of for
six-plus years,” said Bill Geary, who from 1983 to 1989 served as
commissioner of the former Metropolitan District Commission, the agency
that used to be responsible for maintaining Soldiers Field Road. The
approach “was kind of primitive, but it worked. It reduced these
episodes dramatically.”

Then bring in state officials and have them admit in court to a recent up-tick in crashes along these roadways--and how an "awareness campaign" was planned for later this year. Then, have them prepare work orders showing how often DCR people have been asked to survey the condition of the road signs. "Over the years, some signs faded, got lost, or became tangled on the stanchions that support them." Have DCR produce invoices as to how it often it purchased replacement rubber signs indicating the oncoming height of the underpasses.

Whatever you might think of Mr. Jackson's fault with regard to this accident, a judge or jury reviewing the full record is likely to find that fault equally shared by the agency that is the custodian of these roadways. I'm sure poor Mr. Jackson feels terrible about being involved in hurting those children, and there is no purpose served in punishing him further. If I were the State Police, I'd let him go home and live with his own terrible memories of the event.

Monday, February 04, 2013

The story of the Boston bus crash this past weekend takes on a new dimension with the revelation by a spokesperson for the state agency that it had "seen an uptick" recently in the number of vehicles that had been hitting overpasses, "mostly by box trucks, vehicles that you can rent," by people who are not used to driving them. Listen to this interview on Radio Boston.

The inaction by DCR in response to this trend is all the more striking when one considers that the solution to the problem was put in place 30 years ago. It was low-cost, low-tech, and effective: Hang rubber signs saying "cars only" at every entrance to the river roads, at a height equivalent to the coming underpasses. Much has been made of the cowbells that were attached to the signs, but the significant innovation were the signs themselves.

The "up-tick", I 'd like to suggest, is the result of the deterioration of the system Bill Geary put in place in the 1980s. Because of my personal interest in this bit of urban infrastructure, over the last year or two, I have noticed a growing number of instances where the signs have been missing. Often, all that was left were the chains that used to hold the signs. Indeed, sometimes the only things left hanging on the chains were the cowbells!

Based on this interview, it appears that DCR thinks that an awareness campaign is the way to go. Do you really think that an "awareness campaign" will reach those students with U-Hauls every September and June (or the tour bus operators who pass through Boston once or twice in their lives)? Please don't reinvent the wheel. Just restore what worked so well for so many years.